Obstetric Cholestasis (lntrahepatic cholestasis of pregnancy): This is a liver disease specific to pregnancy. Characterized by pruritus affecting the ) • > ) ) whole body but particularly the palms and soles, and abnormal liver function tests. It most commonly occurs in the third trimester of pregnancy and any woman with pruritus without rash should have liver function tests(3 Management: in the absence of premature labour, delivery should be induced at 37-38 weeks(3 _ 2- Vitamin K should be given to the mother (10 mg orally) from there time of diagnosis to reduce the postpartum hemorrhage". 3- Control of symptoms may be achieved by a combination of antihistamines and emollient. And these are insufficient, Ursodeoxycholic acid (UDCA) (300 mg 2-3 1- Current guideline suggest that Following delivery, liver function tests return to normal. Recurrent of obstetric cholestasis is in subsequent pregnancies exceeds 90%

Diagnosis: Diabetes mellitus in pregnancy The pregnancy may be complicated by maternal diabetes mellitus where: A- Women with pre-existing diabetes (and are classified as either IDDM or NIDDM) B- Those developing carbohydrate intolerance during pregnancy (usually during third trimester) and are classified as Gestational Diabetes Mellitus (GDM) . Diagnosis: The American Diabetes Association suggests the following targets for women who develop gestational diabetes during pregnancy. More or less stringent glycemic goals may be appropriate for each patient. . Before meal (preprandial): 95rng/dl or less. • 1 h after meal (postprandial): 140mg/dl or less. • 2 h after meal (postprandial): l 20mg/dl or less.

Complications of GDM 1- Macrosomia (large babies: greater than 4 kg) 2- Hypoglycemia 3- Intrauterine growth retardation 4- Late fetal death 5- Cardiomyopathy (asymmetric septal hypertrophy) 6- Pulmonary hypertension 7- Idiopathic respiratory distress syndrome (RDS) 8- Hyperbilirubinemia 9- Hypocalcemia and hypomagnesemia 10-Thrombosis and abnormal clotting

2-Maternal: ) ) A- Complications of GDM to pregnant women include(4 : 1- Pre-eclampsia and gestational hypertension. 2- Preterm labor. 3- Recurrent vulva-vaginal infection (thrush, UTI ..... ). 4- Long-term development of diabetes mellitus. 5- Increased incidence of operative delivery (like Caesarean section). B-Complications of preexisting diabetes to pregnant women include : 1- Pre-eclampsia and gestational hypertension. 2- Preterm labor. 3- Recurrent vulva-vaginal infection (thrush, UTI ..... ). 4- Increased incidence of operative delivery (like Caesarean section). 5- Exacerbation of pre-existing disease (retinopathy, nephropathy, and cardiac disease).

Management: A- Pregnant woman with preexisting diabetes: 1- The aim is to maintain glucose level within these ranges and to avoid hypoglycemia and hyperglycemia". 2- Most patients: with pre-pregnancy diabetes are taking insulin, and this therapy must be maintained during pregnancy'. 3- For those on oral antidiabetic agents, it is advisable to convert them on insulin , because of the possible teratogenic effects and insulin facilitates a more effective manipulation of requirements as pregnancy progress". 4- In addition to insulin therapy, dietary advice is essential as it make glycemiccontrol with insulin easier.).

B-Pregnant woman with GDM: 1- The aim is to maintain fasting glucose level below l 00 mg/dL (about 5.5 mmol/dL) , below 125 mg/dL (about 7 mmol /dL) for 2 hours post-prandial glucose level, and to avoid hypoglycemia and hyperglycemia". 2- Glucose control can be achieved through": 1- Dietary control. 2- Insulin Therapy": If dietary control does not reduce hyperglycemia sufficiently to • I reach the recommended glucose levels, insulin therapy is needed'. (Note: many practitioners will try to control glucose using dietary method for 2 weeks prior to switching to insulin". The initial starting insulin dose should be based on existing weight. And a total daily insulin dose of 0.5 to 0. 7 units/kg is given. Two thirds of this dose is usually given in the morning and one third in the evening. Also, one third of each dose is given as rapid-acting insulin and the remaining dose as intermediate. The second dose may be divided so that rapid-acting insulin is given at suppertime and intermediate at bed time.

C-Delivery: The most common risk with GDM is macrosomia (large babies), which can lead to birth injuries. Clinical judgment often becomes the determinant on whether cesarean delivery is appropriate . _ )